- Email: [email protected]
EXAMINATION OF A TEACHER FROM EL SALVADOR
213
the fitting from the feed pipes (table 11). We ascertained that opening the taps released sufficient pressure to draw stagnant water containing the organism into the main water flow. Excessive aeration was observed in the water system at Kingston Hospital, which was maintained at a pressure of 60 psi. This pressure is sufficient to generate aerosols of water particles of less than 5 pm diameter in showers.16 Such particles are small enough to penetrate the alveoli and are the most probable vehicle of infection. 17 Some materials used in the manufacture of water components are known to be capable of acting as sources of nutriment for aquatic microorganisms, 18 and since 1975 the NWC has administered a scheme of materials testing designed to ensure that water fittings do not contaminate public water supplies. However, components installed downstream of a back-siphonage device within a fitting or an air break in a plumbing system are not required to be tested for effect on water quality, and the scheme is not mandatory. Thus the hospital’s fittings, which were of an approved type, did not contain NWC-listed washers. The decision to replace all the rubber washers in the hospital’s fittings with an approved type was simple to implement and effective, and a year later we have been unable to isolate L pneumophila from the hospital’s water-systems (table I). This study has identified several important principles concerning the design, construction, and management of complex plumbing systems. Firstly during construction, pipes and tanks are exposed to dirt and surface water which is likely to be contaminated with this ubiquitous environmental organism. After pressure testing, stagnant water remains inside pipes and fittings for long periods, thereby providing opportunities for microbial growth. When a building is commissioned the peripheral pipework and fittings are not always adequately disinfected. Parts such as hot-water cylinders provide reservoirs for the growth ofL pneumophila and other organisms through thermal stratification, scale deposition, corrosion, and operational manoeuvres which cause sudden changes in the direction of water flow. Unsuitable components in fittings, such as showers, provide further foci for growth at water outlets. Fittings contain niches for microbial growth that are physically protected from primary control measures such as chlorine and heat. Pressurisation of water systems and aeration are features which may determine which buildings are most liable to outbreaks of disease. A major study of these and other factors involving a number of large public buildings is now underway. Meanwhile our experience highlights the importance of ensuring that people responsible for water-systems in large public buildings have an adequate understanding of watersupply hygiene. Mandatory rather than voluntary control of the use of materials should also be given serious, consideration.
through
We thank Dr M. Dart (Director, Scientific Services) and Dr J. Ross (Regional Manager, Public Health and Amenities), Thames Water, for supporting this investigation. The National Water Council scheme has transferred to the Water Research Centre and is now known as the United Kingdom Water Fittings Byelaws Scheme.
Correspondence should be addressed to J.
S. C.
REFERENCES 1. Fisher-Hoch
SP, Bartlett CLR, Tobin JO’H, et al. Investigation and control of an legionnaire’s disease in a district general hospital. Lancet 1981; i:
outbreak of 932-36.
Clinical Evidence of Torture EXAMINATION OF A TEACHER FROM EL SALVADOR ON Oct 19,
1983,
a
medical examination
was
carried
out on a
teacher, from El Salvador, who alleged that he 30-year-old had been arrested and tortured eighteen months previously. An man,
a
interpreter was present and medical time of the examination.
photographs were taken at the I
PHYSICAL EXAMINATION
fit right-handed man with a number of scars on the face, buttocks, and both thighs. The scars were of similar appearance and age, with some keloid formation and hyper- and hypo-pigmentation. Each had an irregular outline. Face.- There was an irregular (linear) scar, widest just below and to the left of the midpoint of the lower left eyelid, which extended laterally to the upper anterior rim of the left helix. Thorax and upper arms..-A broad scar began to the right of the midline over the sternum and extended in tapering form across the left pectoral area and appeared to be in continuity with a linear scar which ran across the left upper arm terminating at the outer border of the triceps. There was a stellate scar in the right lateral pectoral He
was a
trunk,
arms,
region. Forearms.-There were faint hyper pigmented linear marks on both wrists. Back.-Two linear scars intersected in the mid-dorsal region. The long component extended from the left posterior axillary line to the right deltoid where it curved forwards and could be seen when the subject was viewed from the front. The shorter scar had a vertical component which began to the right of the midline and crossed obliquely in a cranial direction intersecting the previous scar at right angles and then extending to the right acromial region. Right thigh. -There was a group of scars which radiated from the adductor region and extended as three components: vertically down the leg, diagonally across the back of the thigh, and curving round the thigh (see fig). There was a stellate scar in the natal cleft on both sides which extended close to the anal margin.
2. Fisher-Hoch
SP, Smith MG, Colbourne JS. Legionella pneumophila in hospital hot cylinders. Lancet 1982; i: 1073. National Water Council. Directory of water fittings, vol 2, 1983. Edelstein PH. Improved semiselective medium for the isolation of Legionella pneumophila from contaminated clinical and environmental specimens. J Clin water
3. 4.
Microbiol 1981; 14: 298-303. 5. Smith MG. A 6.
simple disc technique for the presumptive identification of Legionella pneumophila. J Clin Pathol 1982; 35: 1353-55. British Standard Draft for Development. Specification of requirements for suitability of materials for use in contact with water for human consumption with regard to their effect on the quality of the water. London: British Standards Institution,
DD82, 7. Colbourne
1982.
JS, Brown DA. Dissolved oxygen utilisation as an indicator of total microbial activity on non-metallic materials in contact with potable water. J Appl Bacteriol 1979; 47: 223-31. 8. Ashworth JA, Colbourne JS. Requirements for the testing of materials for use in contact with potable water. London: National Water Council, document 108DO1, issue 2, 1982. 9. Tobin JO’H, Bartlett CLR, Waitkins SA. Legionnaire’s disease further evidence to implicate water storage systems as sources. Br Med J 1981; 282: 573. 10 Tobin JO’H, Beare J, Dunhill MS. Legionnaire’s disease in a transplant unit: Isolation of the causative agent from shower baths. Lancet 1980; ii: 118-21. 11. Dennis PJ, Taylor JA, Fitzgeorge RB, et al. Legionella pneumophila in water plumbing systems. Lancet 1982; i: 949-51 12. Wadowsky RM, Yee RB, Mezmar L, et al. Hot water systems as sources of Legianella pneumophila in hospital and non-hospital plumbing fixtures. J Appl Envir Microbiol 1982; 43: 1104-10. 13. Editorial. Waterborne legionellae. Lancet 1983; ii: 381-82. 14. Best M, Yu VL, Stout J, et al. Legionellaceae in the hospital water supply. Lancet 1983; i: 307-10. 15. Colbourne JS. The presence and significance of Pseudomonas aeruginosa in London’s water supplies. Ph D thesis, University of Surrey, 1979. 16. Baskerville A, Fitzgeorge RB, Broster M, et al. Experimental transmission of legionnaires’ disease by exposure to aerosols of Legionella pneumophila. Lancet 1981; ii: 1389-90. 17. Hambleton P, Broster MG, Dennis PJ, et al. Survival of virulent Legionella pneumophila in aerosols. J Hyg (Camb) 1983; 90: 451-60. 18. Burman NP, Colbourne JS. Effect of non-metallic materials on water quality. J Wat Eng Sci 1979, 1: 11-18.
214 adductor region while the individual was recumbent and to the back of the body and natal cleft when he was prone. The distribution of the injuries is not consistent with accidental or self-mutilation. COMMENT
Apart from the application of acid this man gave a history of other experiences, which included beatings, being submerged to drowning point in a sink of water, the forcing of objects into the savage
electrical torture, and the forcible abduction and of his two-year-old son. The purpose of the examination was to establish clinical evidence.
rectum,
disappearance
We thank the
Hospital, London,
Department of Medical Illustration at Charing Cross for undertaking the photographic work. ELIZABETH GORDON, Consultant surgeon; Chairman, British Medical Group of Amnesty International
ARTHUR KEITH MANT, Head, Department of Forensic Medicine, Guy’s Hospital, London: Professor of Forensic Medicine,
University of London
Medicine and the Law Scars
on
thighs
and in natal cleft.
Left thigh.-A
linear
the lower end of the quadriceps thigh terminating over the fascia lata.
scar over
muscles curved around the
OPINION
The hyperpigmented lesions at the wrists are consistent with tight binding and appear to be of a different nature to the remaining scars on his body. The distribution of the scars on his trunk, back, and legs are inconsistent with a self-inflicted injury in a right-handed individual. The irregular outline of the scars and the areas of altered pigmentation together with the keloid elements are consistent with burning, and the state of healing of the scars indicates that they are at least twelve months’ old. The scars on the front of his body and face are broader nearer the midline and narrower where they extend towards the left. The upper scar on his trunk appears to be in continuity with a similar scar on the left upper arm. This would be consistent with scars from a corrosive liquid which had flowed over the body while in a horizontal position. The scar on the right adductor region, with its three linear components extending round the thigh, is also consistent with the flow of a liquid starting in the adductor region and flowing round the back of the thigh while the subject was recumbent. The linear scars on his back are in the pattern of a cross and the upper one has a broadened area consistent with a pooling effect. This is consistent with a flow of liquid while the individual was lying prone. The scar in the natal cleft arises deeply in the cleft and is only seen in its extent on separating the buttocks. The stellate scar in the natal cleft is consistent with a "kiss" injury consequent on the apposition of the skin of the buttocks in muscle contraction as a response to pain elicited by the initial application of a corrosive material by another person. The medical report and clinical photographs were submitted to a forensic pathologist who formed the same conclusion as the medical examiner. CONCLUSION
The scars on the wrist were consistent with binding to the point of restraint. The remaining scars were consistent with burns from a corrosive liquid applied separately to the face, front of the body, and
Surgeon Awarded Damages for Distress Following Wrongful Suspension A part-time orthopaedic consultant in the NHS was awarded damages for distress, frustration, and vexation caused to him by a hospital authority’s breach of contract in requiring him to submit to a medical examination and suspending him from duty when he refused to undergo such an examination. A professional dispute arose between the plaintiff surgeon and a colleague. Following this, heated correspondence was exchanged
between them while the plaintiff was on six months’ leave in Australia. The colleague referred the correspondence to the regional medical officer and invited him to suspend the plaintiff surgeon on his return. The medical officer discussed the situation with a subcommittee of the medical staff committee, who felt there might be a risk to patients as a result of the plaintiffs behaviour. When the plaintiff returned from Australia, the chairman of the Health Authority required the surgeon to undergo a psychiatric examination. The surgeon refused, whereupon he was suspended by the chairman. An internal committee of inquiry raised the suspension and withdrew the requirement for the surgeon to undergo a medical examination. He continued to receive his salary while he was suspended. The plaintiff surgeon claimed damages for wrongful dismissal, since he had concluded it would not be possible for him to return to work at the same hospital. The defendant regional health authority were in breach of contract in requiring the plaintiff to undergo a medical examination and suspending him from duty. Accordingly, the plaintiff surgeon was entitled to damages for loss of income from his private practice, and to damages arising from the authority’s breach of contract in respect of his stress, frustration, and vexation, since it was reasonably foreseeable by the parties that the plaintiff surgeon would suffer injury of this kind when he was required to undergo a psychiatric examination and, on his refusal, to being suspended from the hospital. Mr Justice Farquharson awarded the surgeon damages of [,9700, including 2000 for distress. The judge said that the regional medical officer and the chairman of the Authority must have realised the effect of their actions on the surgeon. A professional man was peculiarly vulnerable when the balance of his mind was brought into question. Queen’s Bench Division, Dec 9, 1983.
DIANA
BRAHAMS,
Barrister-at-Law
the fitting from the feed pipes (table 11). We ascertained that opening the taps released sufficient pressure to draw stagnant water containing the organism into the main water flow. Excessive aeration was observed in the water system at Kingston Hospital, which was maintained at a pressure of 60 psi. This pressure is sufficient to generate aerosols of water particles of less than 5 pm diameter in showers.16 Such particles are small enough to penetrate the alveoli and are the most probable vehicle of infection. 17 Some materials used in the manufacture of water components are known to be capable of acting as sources of nutriment for aquatic microorganisms, 18 and since 1975 the NWC has administered a scheme of materials testing designed to ensure that water fittings do not contaminate public water supplies. However, components installed downstream of a back-siphonage device within a fitting or an air break in a plumbing system are not required to be tested for effect on water quality, and the scheme is not mandatory. Thus the hospital’s fittings, which were of an approved type, did not contain NWC-listed washers. The decision to replace all the rubber washers in the hospital’s fittings with an approved type was simple to implement and effective, and a year later we have been unable to isolate L pneumophila from the hospital’s water-systems (table I). This study has identified several important principles concerning the design, construction, and management of complex plumbing systems. Firstly during construction, pipes and tanks are exposed to dirt and surface water which is likely to be contaminated with this ubiquitous environmental organism. After pressure testing, stagnant water remains inside pipes and fittings for long periods, thereby providing opportunities for microbial growth. When a building is commissioned the peripheral pipework and fittings are not always adequately disinfected. Parts such as hot-water cylinders provide reservoirs for the growth ofL pneumophila and other organisms through thermal stratification, scale deposition, corrosion, and operational manoeuvres which cause sudden changes in the direction of water flow. Unsuitable components in fittings, such as showers, provide further foci for growth at water outlets. Fittings contain niches for microbial growth that are physically protected from primary control measures such as chlorine and heat. Pressurisation of water systems and aeration are features which may determine which buildings are most liable to outbreaks of disease. A major study of these and other factors involving a number of large public buildings is now underway. Meanwhile our experience highlights the importance of ensuring that people responsible for water-systems in large public buildings have an adequate understanding of watersupply hygiene. Mandatory rather than voluntary control of the use of materials should also be given serious, consideration.
through
We thank Dr M. Dart (Director, Scientific Services) and Dr J. Ross (Regional Manager, Public Health and Amenities), Thames Water, for supporting this investigation. The National Water Council scheme has transferred to the Water Research Centre and is now known as the United Kingdom Water Fittings Byelaws Scheme.
Correspondence should be addressed to J.
S. C.
REFERENCES 1. Fisher-Hoch
SP, Bartlett CLR, Tobin JO’H, et al. Investigation and control of an legionnaire’s disease in a district general hospital. Lancet 1981; i:
outbreak of 932-36.
Clinical Evidence of Torture EXAMINATION OF A TEACHER FROM EL SALVADOR ON Oct 19,
1983,
a
medical examination
was
carried
out on a
teacher, from El Salvador, who alleged that he 30-year-old had been arrested and tortured eighteen months previously. An man,
a
interpreter was present and medical time of the examination.
photographs were taken at the I
PHYSICAL EXAMINATION
fit right-handed man with a number of scars on the face, buttocks, and both thighs. The scars were of similar appearance and age, with some keloid formation and hyper- and hypo-pigmentation. Each had an irregular outline. Face.- There was an irregular (linear) scar, widest just below and to the left of the midpoint of the lower left eyelid, which extended laterally to the upper anterior rim of the left helix. Thorax and upper arms..-A broad scar began to the right of the midline over the sternum and extended in tapering form across the left pectoral area and appeared to be in continuity with a linear scar which ran across the left upper arm terminating at the outer border of the triceps. There was a stellate scar in the right lateral pectoral He
was a
trunk,
arms,
region. Forearms.-There were faint hyper pigmented linear marks on both wrists. Back.-Two linear scars intersected in the mid-dorsal region. The long component extended from the left posterior axillary line to the right deltoid where it curved forwards and could be seen when the subject was viewed from the front. The shorter scar had a vertical component which began to the right of the midline and crossed obliquely in a cranial direction intersecting the previous scar at right angles and then extending to the right acromial region. Right thigh. -There was a group of scars which radiated from the adductor region and extended as three components: vertically down the leg, diagonally across the back of the thigh, and curving round the thigh (see fig). There was a stellate scar in the natal cleft on both sides which extended close to the anal margin.
2. Fisher-Hoch
SP, Smith MG, Colbourne JS. Legionella pneumophila in hospital hot cylinders. Lancet 1982; i: 1073. National Water Council. Directory of water fittings, vol 2, 1983. Edelstein PH. Improved semiselective medium for the isolation of Legionella pneumophila from contaminated clinical and environmental specimens. J Clin water
3. 4.
Microbiol 1981; 14: 298-303. 5. Smith MG. A 6.
simple disc technique for the presumptive identification of Legionella pneumophila. J Clin Pathol 1982; 35: 1353-55. British Standard Draft for Development. Specification of requirements for suitability of materials for use in contact with water for human consumption with regard to their effect on the quality of the water. London: British Standards Institution,
DD82, 7. Colbourne
1982.
JS, Brown DA. Dissolved oxygen utilisation as an indicator of total microbial activity on non-metallic materials in contact with potable water. J Appl Bacteriol 1979; 47: 223-31. 8. Ashworth JA, Colbourne JS. Requirements for the testing of materials for use in contact with potable water. London: National Water Council, document 108DO1, issue 2, 1982. 9. Tobin JO’H, Bartlett CLR, Waitkins SA. Legionnaire’s disease further evidence to implicate water storage systems as sources. Br Med J 1981; 282: 573. 10 Tobin JO’H, Beare J, Dunhill MS. Legionnaire’s disease in a transplant unit: Isolation of the causative agent from shower baths. Lancet 1980; ii: 118-21. 11. Dennis PJ, Taylor JA, Fitzgeorge RB, et al. Legionella pneumophila in water plumbing systems. Lancet 1982; i: 949-51 12. Wadowsky RM, Yee RB, Mezmar L, et al. Hot water systems as sources of Legianella pneumophila in hospital and non-hospital plumbing fixtures. J Appl Envir Microbiol 1982; 43: 1104-10. 13. Editorial. Waterborne legionellae. Lancet 1983; ii: 381-82. 14. Best M, Yu VL, Stout J, et al. Legionellaceae in the hospital water supply. Lancet 1983; i: 307-10. 15. Colbourne JS. The presence and significance of Pseudomonas aeruginosa in London’s water supplies. Ph D thesis, University of Surrey, 1979. 16. Baskerville A, Fitzgeorge RB, Broster M, et al. Experimental transmission of legionnaires’ disease by exposure to aerosols of Legionella pneumophila. Lancet 1981; ii: 1389-90. 17. Hambleton P, Broster MG, Dennis PJ, et al. Survival of virulent Legionella pneumophila in aerosols. J Hyg (Camb) 1983; 90: 451-60. 18. Burman NP, Colbourne JS. Effect of non-metallic materials on water quality. J Wat Eng Sci 1979, 1: 11-18.
214 adductor region while the individual was recumbent and to the back of the body and natal cleft when he was prone. The distribution of the injuries is not consistent with accidental or self-mutilation. COMMENT
Apart from the application of acid this man gave a history of other experiences, which included beatings, being submerged to drowning point in a sink of water, the forcing of objects into the savage
electrical torture, and the forcible abduction and of his two-year-old son. The purpose of the examination was to establish clinical evidence.
rectum,
disappearance
We thank the
Hospital, London,
Department of Medical Illustration at Charing Cross for undertaking the photographic work. ELIZABETH GORDON, Consultant surgeon; Chairman, British Medical Group of Amnesty International
ARTHUR KEITH MANT, Head, Department of Forensic Medicine, Guy’s Hospital, London: Professor of Forensic Medicine,
University of London
Medicine and the Law Scars
on
thighs
and in natal cleft.
Left thigh.-A
linear
the lower end of the quadriceps thigh terminating over the fascia lata.
scar over
muscles curved around the
OPINION
The hyperpigmented lesions at the wrists are consistent with tight binding and appear to be of a different nature to the remaining scars on his body. The distribution of the scars on his trunk, back, and legs are inconsistent with a self-inflicted injury in a right-handed individual. The irregular outline of the scars and the areas of altered pigmentation together with the keloid elements are consistent with burning, and the state of healing of the scars indicates that they are at least twelve months’ old. The scars on the front of his body and face are broader nearer the midline and narrower where they extend towards the left. The upper scar on his trunk appears to be in continuity with a similar scar on the left upper arm. This would be consistent with scars from a corrosive liquid which had flowed over the body while in a horizontal position. The scar on the right adductor region, with its three linear components extending round the thigh, is also consistent with the flow of a liquid starting in the adductor region and flowing round the back of the thigh while the subject was recumbent. The linear scars on his back are in the pattern of a cross and the upper one has a broadened area consistent with a pooling effect. This is consistent with a flow of liquid while the individual was lying prone. The scar in the natal cleft arises deeply in the cleft and is only seen in its extent on separating the buttocks. The stellate scar in the natal cleft is consistent with a "kiss" injury consequent on the apposition of the skin of the buttocks in muscle contraction as a response to pain elicited by the initial application of a corrosive material by another person. The medical report and clinical photographs were submitted to a forensic pathologist who formed the same conclusion as the medical examiner. CONCLUSION
The scars on the wrist were consistent with binding to the point of restraint. The remaining scars were consistent with burns from a corrosive liquid applied separately to the face, front of the body, and
Surgeon Awarded Damages for Distress Following Wrongful Suspension A part-time orthopaedic consultant in the NHS was awarded damages for distress, frustration, and vexation caused to him by a hospital authority’s breach of contract in requiring him to submit to a medical examination and suspending him from duty when he refused to undergo such an examination. A professional dispute arose between the plaintiff surgeon and a colleague. Following this, heated correspondence was exchanged
between them while the plaintiff was on six months’ leave in Australia. The colleague referred the correspondence to the regional medical officer and invited him to suspend the plaintiff surgeon on his return. The medical officer discussed the situation with a subcommittee of the medical staff committee, who felt there might be a risk to patients as a result of the plaintiffs behaviour. When the plaintiff returned from Australia, the chairman of the Health Authority required the surgeon to undergo a psychiatric examination. The surgeon refused, whereupon he was suspended by the chairman. An internal committee of inquiry raised the suspension and withdrew the requirement for the surgeon to undergo a medical examination. He continued to receive his salary while he was suspended. The plaintiff surgeon claimed damages for wrongful dismissal, since he had concluded it would not be possible for him to return to work at the same hospital. The defendant regional health authority were in breach of contract in requiring the plaintiff to undergo a medical examination and suspending him from duty. Accordingly, the plaintiff surgeon was entitled to damages for loss of income from his private practice, and to damages arising from the authority’s breach of contract in respect of his stress, frustration, and vexation, since it was reasonably foreseeable by the parties that the plaintiff surgeon would suffer injury of this kind when he was required to undergo a psychiatric examination and, on his refusal, to being suspended from the hospital. Mr Justice Farquharson awarded the surgeon damages of [,9700, including 2000 for distress. The judge said that the regional medical officer and the chairman of the Authority must have realised the effect of their actions on the surgeon. A professional man was peculiarly vulnerable when the balance of his mind was brought into question. Queen’s Bench Division, Dec 9, 1983.
DIANA
BRAHAMS,
Barrister-at-Law